I definitely have mixed emotions regarding the new health care reform bill. I don't know everything that's in it, yet, but what I do know bothers me intensely.

Perhaps I think of the entire health care issue a bit differently from most people?

For me health care is a public policy issue similar to the way we deal with fire departments, public school, or national parks. In other words, the choices we make here have an effect on all of us, not just on those of us directly involved. A house that burns down isn't just a problem for the home owner. People who don't know how to read or write in our modern world aren't just a problem for themselves. Losing the areas we've designated as national parks doesn't just mean fewer places to go and enjoy nature. And like them, people without adequate health care are not just a sad story to read about. The effects are far reaching, both economically and socially.

It's not like some people want to characterize it: we need to be nice to each other and take care of each other. I mean, that'd be nice, too, but adequate health care for everyone is necessary for rather more bloody minded, hard headed reasons.

So I see the whole thing as a three part problem.

1. Health care is too damned expensive. Bills are itemized down to the fare-thee-well. You're charged for a change in rubber gloves, for every single aspirin, and the charges are outlandish. Every doctor and p.a. that has a poke at you submits their own bill. If you walk out with something like a pair of crutches you may well end up getting a bill from some medical supply store in Timbuktu.

   Didn't use to be like that.

2. Insurance is about risk management. Now, you might argue that you don't take risks, so you should pay less for your insurance than others who take more risks. Or perhaps you're willing to bear a greater risk. But that flies in the face of the economic realities of health care. Risk management works best when the entire population is included, rather than allowing groups to take some kind of privileged position.

   In other words, a single payer system that has the entire US population as subscribers is what will be most efficient and most effective at managing the cost of health care.

   Yup, no choice. But you're trying to hold onto an illusion of choice. It's not a real choice. Whatever insurance plan you currently have is governed by actuarial tables, coupled with some sort of commitment of profits to investors. Everything else devolves from there. Your own input here only means something if you incur catastrophic expenses that will have to be paid for by the part of the system outside of your insurance plan. And that's precisely the problem.

3. The tail is wagging the dog. The reason why there's even a question about how we deal with the health care issue is because there are far too many people making money doing everything but providing health care, and any attempt to change that is bound to generate a lot of opposition from a lot of very wealthy people who are trying to maintain the status quo. About 2/3 of all the money spent on health care goes here.

   But in one respect health care reform has to deal with that: these millions of people currently employed doing everything from collecting payments to denying health care can't actually be tossed out into the streets by closing down the likes of Blue Cross Blue Shield, right?

Essentially, a health care plan has to do all of that.

It needs to find a way to return medical billing to sanity. Do away with the practice of charging $1,000 for a hang nail, all but $50 of which ends up being disallowed by the insurance plan anyway.

A single payer system means that you will be able to get medical care whenever you need it, and, more importantly, providers of medical care don't need to inflate costs to recoup from people with the ability to pay the money they lose on the people who don't have the ability to pay.

The hard part would be re-purposing the machinery currently devoted to inefficiency and greed, the health insurance companies and their employees. I gather there's a shortage of nursing staff and doctors. Hey, I have an idea.

Anyway, as far as I can tell, the recently passed health care bill does practically none of all that. I know, the Senate version is still to come, and then there's final conference version... I wouldn't be surprised to find that it makes some things worse.

So that's why I have these mixed emotions. Should I be happy that we had movement of any kind on this issue? Or should we have scrapped this bill and tried again later?